Factors affecting follow-up adherence following Mohs micrographic surgery in patients with nonmelanoma skin cancer: A retrospective chart review
Authors: Sumrah Jilani, Nina M. D'Amiano, Katherine G. Thompson, Jeremy Ellis, Anjali D'Amiano, Elena Wei, Kristin P. Bibee, Jeffrey F. Scott
Journal: Journal of the American Academy of Dermatology (2023)

To the Editor: Patients with nonmelanoma skin cancer (NMSC) are at increased risk for developing additional skin cancers, especially in the first few years after diagnosis. The National Comprehensive Cancer Network Guidelines recommend that patients with NMSC follow-up every 6 months for full-body skin examinations for the first several years after diagnosis.1National Comprehensive Cancer NetworkBasal cell skin cancer (version 1.2023).https://www.nccn.org/professionals/physician_gls/pdf/nmsc.pdfDate accessed: June 21, 2023Google Scholar This study aims to evaluate patient adherence to follow-up recommendations and identify factors associated with follow-up adherence. We conducted a retrospective chart review of 385 patients treated with Mohs micrographic surgery (MMS) for NMSC by Johns Hopkins Dermatology. The study was approved by our institutional review board. We collected demographics, medical history, tumor and surgery characteristics, dates of follow-up visits, postoperative complications, and subsequent skin cancer diagnoses for 2 years following diagnosis. Negative binomial regression models were used to model outcomes that are counts. Follow-up adherence was modeled using weighted least-squares logistic regression for grouped data. Data were analyzed using STATA 17 (StataCorp). Our study cohort included 385 patients (65.5% male, 96.4% White, 1.6% Hispanic or Latino) with a mean of 68.0 ± 12.9 years. Tumor types included 313 basal cell carcinomas (43.9%), 92 squamous cell carcinomas (19.5%), and 67 squamous cell carcinomas in situ (14.2%). We found that the majority of patients treated with MMS at our institution did not complete all recommended follow-up visits in the first 2 years following a NMSC diagnosis, with 21.6% not receiving any follow-up dermatologic care within our department during this period. This is concerning given that over half (54%) of the patients who completed at least 1 follow-up visit had at least 1 new skin cancer identified during the follow-up period (Table I).Table ISummary of follow-up visitsFollow-up metricNumberFollow-up visits, n1649General dermatology visits1192 (72.3%) Visits with full body skin exam835 (70.1%) Visits with focused skin exam277 (23.2%) Visits addressing other concern80 (6.7%) Patients who completed 0 follow-up visits83 (21.6%) Patients who completed at least 1, but not all follow-up visits202 (52.4%) Patients who completed all follow-up visits100 (30.0%) General dermatology visits with 1+ new skin cancer diagnosed238 (20.0%) Surgical postoperative visits with 1+ new skin cancer diagnosed31 (6.8%)Patient level follow-up completion # of surgical postoperative visits, median (IQR)1 (0, 2) # of general dermatology visits, median (IQR)3 (1, 5) # of 6-mo follow-up checkpoints met, median (IQR)3 (1, 4) Percentage of expected follow-ups completed, median (IQR)60% (25%, 100%)New skin cancers diagnosed, n440 Patients who completed at least 1 follow-up visit302 (78.4%) Patients who followed up and had at least 1 new skin cancer diagnosed during follow-up139 (46.0%) Patients who completed all follow-up and had at least 1 new skin cancer diagnosed56 (56.0%) Open table in a new tab Factors significantly associated with higher follow-up adherence included history of prior NMSC (odds ratio [OR] = 1.58, P = .001) or history of other nondermatologic solid tumor (OR = 1.66, P = .015). Factors significantly associated with lower follow-up adherence included having Medicaid as primary insurance (OR = 0.84, P = .042) and first-time MMS (OR = 0.59, P < .001) (Table II). Many of our findings were consistent with prior studies, which have found that patients who have a history of skin cancers or prior clinical skin examinations may be more likely to follow-up and adhere to treatment.2Kalimullah F.A. Brown C.W. Compliance with follow-up among patients with melanoma and non-melanoma skin cancers.Dermatol Online J. 2014; 20https://doi.org/10.5070/d3202021537Crossref PubMed Google Scholar,3Janda M. Youl P.H. Lowe J.B. Elwood M. Ring I.T. Aitken J.F. Attitudes and intentions in relation to skin checks for early signs of skin cancer.Prev Med. 2004; 39: 11-18https://doi.org/10.1016/j.ypmed.2004.02.019Crossref PubMed Scopus (63) Google Scholar Other researchers have also reported Medicaid insurance status as a factor in missed appointments and reduced follow-up rates, citing factors such as time, lack of transportation, and financial barriers, which may pose more of a burden in this population.4Freije S.L. Holmes J.A. Rachidi S. Ellsworth S.G. Zellars R.C. Lautenschlaeger T. Demographic factors associated with missed follow-up among solid tumor patients treated at a large multi-site academic institution.Future Oncol. 2020; 16: 2635-2643https://doi.org/10.2217/fon-2020-0425Crossref PubMed Scopus (3) Google Scholar,5Cronin P.R. Decoste L. Kimball A.B. A multivariate analysis of dermatology missed appointment predictors.JAMA Dermatol. 2013; 149: 1435-1437Crossref PubMed Scopus (28) Google ScholarTable IIFactors associated with follow-up adherenceFactorORSE[95% CI]P valueAge1.010.011.001.02.092 <50Ref 50-591.130.340.622.06.680 60-691.470.370.892.43.130 70-791.690.441.012.84.045 ≥801.500.420.862.60.148Sex FemaleRef Male0.870.130.651.16.348Primary insurance PrivateRef Medicare1.260.180.961.66.097 Medicaid0.840.070.710.95.043 Uninsured2.532.140.4813.41.273 Immunosuppressed1.020.170.731.43.892 Taking blood thinners1.110.150.841.46.466Number of previous skin cancers 0Ref 11.330.250.921.93.128 21.810.421.152.85.011 3+1.670.271.212.31.002 First time Mohs0.590.080.450.76<.001Number of prior Mohs/WLE 0Ref 11.860.331.312.66.001 21.990.501.213.27.007 3+1.470.251.052.06.024Comorbidities Congestive heart failure0.810.220.471.39.433 Chronic kidney disease (mod—severe)1.080.230.701.65.737 History of other solid tumor cancers1.660.341.102.49.015 CCI Score1.010.030.961.07.592Bolded values signify statistical significance with P < .05.CCI, Charlson comorbidity index; OR, odds ratio; Ref, reference value; WLE, wide local excision. Open table in a new tab Bolded values signify statistical significance with P < .05. CCI, Charlson comorbidity index; OR, odds ratio; Ref, reference value; WLE, wide local excision. Our study was conducted at a single institution and limited to data obtainable from patients' medical records. In conclusion, our study identified several populations at risk for lower follow-up adherence following MMS for NMSC, including patients with Medicaid insurance and without prior skin cancer history. Further data should be collected directly from patients in order to better understand the specific factors that affect follow-up adherence and subsequently guide quality improvement interventions. None disclosed. We would like to acknowledge support for the statistical analysis from the National Center for Research Resources and the National Center for Advancing Translational Sciences (NCATS) of the National Institutes of Health through Grant Number 1UL1TR001079.